04080056CI TY OF CUPERTINO
'
@'*' v: ^As+z' sca-x r,•e
T, ACT,
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
4qo VAT
C & C VALLEY CONST.
PERMITNo04080056
All OWNER'S NAME:
PERMIT ISSUE DATE
10 9
E:
SANITARY O. C OL NO,
ARCHITECT'/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
.Job Description
I hcuby affrm Nat 1 stn limen d undcr provision of Chapmr 9 (commencing
with Sccdon ]GONE of Diin vi,ian J Of du Business and ProlCssiuns Code. and my license is
full f erect.
REVISION--TRUSS CAL
L ,ion Clara lass Lt.. X
Lx
Dam Comractnr
NO NEW PERMIT ISSUED/ ORIG. #04040120
ARCHITECTS DECLARATION
1 understand my plans shall hcused as Puhlic recnous
Licensed P.(cuiunal
OWNER-BUILDER DECLARATION
1 hereby stator that 1 am exempt from the Commuters License Law for the
fallowing uuon. (Section 7031.5. Business and Profe ions Code: Any city ar county
which reunions, permit 1. construct. alter, implore, dcmnlLah,o, repel, any structure
! pnorto itsissuance. plan require the applicant for such permit to file a signed statement
9
Sq. Ft. Floor Area
Valuati
that he is licensed pursuant the previsions of the Chilli License Law (Chapter
(commencing with Section ]ao0)of Division 3 of the Business and Profeainna Coda) or
1115
• I that be is exempt therefrom and the bun for the alleged exemption. Any vlolallon of
APN Number -
Occupancy Type
Section ]031.5 by any applicant for a permit subjects the applicant o a civil Penalty Of
out more Nan five hundred dollars ($503).
36205022'00
r
❑I.uowne+ofthe properly. or my cmploycuwith wagasstkir sole eompenution,
Required Inspections
q P
will do the work, and the structure is not intended or offered for save (Sec.]Da. Business
and Pronasions code: The Continental, Liana law don m, .11,m ,a owns, Of
property who builds or improves thereon, and who does such work himself or through his
own employee, provided the, suchover improvements arc not moRercd for Bata 1L
arofintended
builder, the buildingvthorimprovementissoldwithinone year the owner
mprove
\
or
for
bele.). will have the burden of proving Nva he did not build or improve far puryose of
tile.).
/
I. u owner or the am exclusively Pretensions with eonwcross t.
O
Sec.1property.
Code:) The Co thereon. Lid
;) The
camwm the is not (Sec. ]04x, Guiness and ray who Wilds or improve and
dna not apply je ts owner of property who
s
COmon.
wholaw
sed p
who convects for such projects with a contractor(s) licensed pursuant m the Conwner`3
,
License Law.
❑lam exem yn\dojo see ,B&PCT rah', rcsson
Owner
WORK ENSATION DEC RA ON
cl V VK
I hereby allnt under Penalty Of perjury one of the to lowing declarations:
haw and sal Section Of fortfor
the Labor Code, acroor,Gnmpm-
s on, ss provided for by Section J]o0 of to labor Code, for the pc,(oemance of the
ode for 37M
work for which this permit is issued.
I have and will ..Intel. Workers Compensation lmunn., u required by Sccdon
3]00 of the labor Code, for the pernrmxnce Of the work forwhich this permit is Issued.
My Worou', COmpensad m Imuran. carrier and Pali, numbe, are:
Cartier. Poli, No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Btu section need not beeompleted if the permit is (mune hundred dollars (SIM)
or tcsL)
1 ccrdfy that in the perfrmerme or the work for which this permit is issued. 1 still not
employ any person in any manncru as in become subject to the Workcri Compensation
Laws of Califamna. Dau
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subjen to the Worker's Compensation provisions of the Labor CMC, you must
t
' fonhwitlt comply with such provisions or this Permit shall be deemed mvnkcd.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there iss comwnnn agcn, for the pedoemantt Of
7. Cin.
' the work for which this permit is issued (Sec. ]097. Civ. C.)
lenders Name
1<ndcrs Address
1 cenify 0.11 have read this xppliclown pad suns that Ne shove information is
' correct. I agree to comply with all city and county ordinances and soon taws relating in
building construction, and hereby authorise representatives of this citym cnrerupnn the
above-mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cuperino against
] Ilabilitiu,judgmem. Com and expenses which may in any way aceme against said City
in consequence of the granting of this Permit.
APPLICANT UNJQERSTANDS AND WILL COMPLY WITHfsLL NON-POINT
Issued by:9 Date
SOLUM" IONS. /� lO
Type of Roof
\\YY�I PS / /1\3e-roofs
Sign of Applic ✓Com nor Data
DOES MATERIALS DISCLOSU E
ill the applicant or future building Occupant store or handle havarduus material
as reed by the Cupertino Mum taxi Code. Chapter 9.13. and the Health and Safety
Coca, second u53z(a)]
All roofs shall be inspected prior to any roofing material being installed.
�Jj
❑Ye �Nr
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or device which
haxardnus airconfldroxs defined by the Bay Area Air Quality Management
all new materials for inspection.
m]
❑Yes u
I have mail the huardoemamrialsmquirmunts underChapter G95 of the Califon
nix Health&SafetyCode, Soctimo 25NI5,25533 and 25534.1 understand" iftM building
4. not curendy have • ummi. Nat it Is my haponsibiloy 0 notify ft attno., of the
OgCiremeno wni m me re m'""O'eoraccnlfcauof upas,
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or authorized egesta — 6enal 1